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Surveys & Forms > UNUM > UNUM Beneficiary form

GROUP INSURANCE BENEFICIARY FORM

Employee Information:

First Name Last Name
Address
City
State Zip
E-Mail
Work Phone Home Phone

Beneficiary Information *(for Life Insurance Coverage provided by MVCC PA Benefits Fund)
Last Name
First Name
Middle Initial
Relationship to You:
Benefit %

Alternate Beneficiary Information:
If the Beneficiary(ies) named above are not living, then pay:
Last Name
First Name
Middle Initial
Relationship to You:
Benefit %

*Note: Benefits cannot be sent directly to a minor. Please contact Paul Halko for further information.

Request for Signature and Certification:

I understand that my insurance coverage may be subject to exclusions, limitations, delayed effective dates and benefit offsets, as described in the enrollments materials or employee booklet(s) that have been provided to me by the MVCC Professional Association Benefits Trust Fund.

In order to be eligible for individual and family benefits under the MVCC Professional Association Benefits Trust Fund, a bargaining unit member must have completed six (6) contiguous months of full-time employment in a bargaining unit position. Six (6) months equals one hundred eighty (180) calendar days.

A bargaining unit member who has achieved eligibility as above and is on an authorized leave of absence as provided for in Article 11 of the Collective Bargaining Agreement between the Mohawk Valley Community College Professional Association and the County of Oneida and the Board of Trustees of Mohawk Valley Community College shall continue to be eligible for benefits provided by the MVCC Professional Association Benefits Fund for the duration of the leave of absence up to a maximum of two years.

A bargaining unit member on a term appointment and who has achieved eligibility as above whose appointment expires and who is rehired to the bargaining unit shall be eligible for benefits provided by the MVCC Professional Association Benefits Trust Fund. Such Eligibility shall begin within sixty (60) days of a bargaining unit member's full-time employment in a bargaining unit position provided that this resumption is less than one hundred eighty (180) calendar days following the expiration of his/her previous appointment.

I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request.

_____________________________
Employee Signature

________________________
Date

 

 

 

 

 

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